Mammography

 Patrick Simon – History, Physics, and X-ray/ Breast Interaction

 Kim Carpenter – Procedure and Equipment
 Joe Shonkwiler – Diagnosis
 Maggie Nelsen – Benefits, Risks, and Limitations
History of Mammography
 Used in clinical practice since
1927 in diagnosis of breast
abnormalities.
 In the 50’s and 60’s it was
developed to the point that
benign and malignant tumors
could be differentiated.
 1963-1967 screening program for
the detection of breast cancer
conducted by the Health
Insurance Plan of New York
(60,000 women screened).
 1973 Breast Cancer Detection
Demonstration Project
(B.C.D.D.P.) – 15 annual
screenings of 270,000 women.
Low Dose X-rays
 Electrons originating at
the cathode are
accelerated towards the
rotating anode.
 Upon contact the kinetic
energy of the electron is
converted into x-rays and
heat (0.5% x-rays)
 Collimator system,
composed of lead for
complete absorption,
focuses the x-ray beam
Breast Anatomy and
Development
 Layers include skin, subdermal adipose tissue,
connective tissue stroma: blood vessels, lymph
channels, and more adipose tissue.
 Included in the stroma are the glandular
tissues responsible for milk production. They
consist of milk forming lobules and an
extensive draining system.
 Glandular tissues, the origin of most breast
carcinomas, are most dense after puberty until
menopause, thus, dictating the effectiveness of
mammography.
The Breast
 A ducts
 B lobules
 C dilated section of duct to
hold milk
 D nipple
 E fat
 F pectoralis major muscle
 G chest wall/rib cage
 Enlargement:
 A normal duct cells
 B basement membrane
 C lumen (center of duct)
X-ray/ Breast Interaction
 As with most x-ray images greater contrast occurs
when there is a large difference in attenuation between
tissues.
 The breast is compressed and the x-ray beam is
applied.
 Contrast is best seen between fatty tissue and
functional glandular tissue, but contrast is poor
between glandular tissue and cancerous tissues.
 Thus, in older women, post-menopause, the reduction
in functional glandular tissue provides for a distinct
contrast between cancerous masses and fatty tissues.
Two Types of
Mammograms
 A screening mammogram is an x-ray examination of the breast in a
woman who has no breast complaints (asymptomatic). The goal of
screening mammography is to find cancer when it is still too small to
be felt by her doctor or the woman.
 A screening mammogram usually takes 2 x-ray pictures (views) of
each breast.
 A diagnostic mammogram is an x-ray examination of the breast in a
woman who either has a breast complaint (for example, a breast mass,
nipple discharge, etc.) or has had an abnormality found during a
screening mammogram. During a diagnostic mammogram, more
pictures will be taken to carefully study the breast condition.
Mammogram Equipment
 A mammography unit is a
rectangular box that houses a tube in
which x-rays are produced. Attached
to the unit is a device that holds and
compresses the breast and positions
it so images can be obtained at
different angles.
 Modern technique uses a special
machine exclusively for breast x-
rays to produce studies that are high
quality but have a low radiation dose
(usually about 0.1 to 0.2 rad dose
per picture).
Mammogram Equipment
Cont.
 A mammogram device has
special accessories that
allow only the breast to be
exposed to the x-rays.
 x-rays do not penetrate
tissue as easily as the x-ray
used for routine chest films
or x-rays of the arms or
legs.
Mammogram Procedure
 The breast is first placed on a platform and
squeezed between 2 plates
 Breast compression is necessary to:
1) even out the breast thickness so all tissue can be
visualized
2) spread out tissue so small abnormalities won't
be obscured by overlying breast tissue
3) allow the use of a lower x-ray dose since a
thinner amount of breast tissue is being imaged
4) hold the breast still to eliminate blurring of
image caused by motion
5) reduce x-ray scatter to increase sharpness of
picture.
Mammogram Procedure
Cont.
 While the breast is being compressed, an image is produced as a result of
some of the x-rays being absorbed (attenuation) while others pass
through the breast to expose either a film or digital image receptor.
 The image is then read by a radiologist.
Reading the Mammogram
 Best if read by radiologist specializing in mammography
 Important to recognize even the smallest abnormalities
 Multiple films and angles are often necessary
 Sometimes two physicians will read the same film for the most thorough
assessment
 Computer based digital mammography is used to get maximum information
from each mammogram taken
 Comparison with older films is also extremely useful
BI-RAD(Breast Imaging Reporting
and Data System) Categories

 BI-RAD 1 Negative (N): No comments, breasts are normal

 BI-RAD 2 Benign Finding-Negative (B): Negative, but the
radiologist may want to elaborate upon the presence of a
benign finding
 BI-RAD 3 Probably Benign Finding (P): A finding is on a
mammogram, and it is most certainly benign, but needs to
be observed for changes
 BI-RAD 4 Suspicious Abnormality (S): Possibility of lesion
in breast being malignant
 BI-RAD 5 Highly Suggestive of Malignancy (M): High
probability of cancer, actions should be taken
Mammographic Masses
A mass is localized collection of
tissue
Characteristics:
 Shape: a smooth defined
lobule is usually benign, but a
ragged edge can be malignant
 Margins: characterization of
the edge or transition between
a mass and surrounding
normal fatty tissue
 Density: degree of X-ray
attenuation is defined relative
to the expected attenuation of
an equal volume of normal
glandular breast tissue (the
majority of breast cancers
have high attenuation)
Mammographic
Calcifications
 1/3 of breast cancers are
associated with
calcification
 Benign calcifications are
often larger than
malignant calcifications
 Distribution and number
of calcifications is
especially important
 Shape of calcifications is
always duly noted
Now, you be the
radiologist…
 Benefits vs. Risks
Benefits
 Ability to detect small tumors
 Greater treatment options
 Cure is more likely
 Increases detection of DCIS
 Ductal carcinoma in situ
 Only method to detect these
tumors
 Harmless if removed early
Risks
 Effective radiation dose is 0.7mSv
 Equals background radiation
received in three months
 Interference by pregnancy
 False Positive Mammograms
 5-10% of tests require follow-ups
 Ages 40-49
 30% chance of false positive
 7-8% chance of having a biopsy
with 10 years
 Ages 50 and over
 25% chance of false positive
Limitations of
Mammography
 Interpretations of mammograms
 Normal breasts are different for each woman
 Images can be compromised
 Cancers are hard to visualize
 Not all cancers can be seen on mammography
 Breast implants can impede accurate readings
 Silicone and saline implants are not transparent
 There are ways to compress the breasts to
improve the view without rupturing the implant